Third Party Delegation. The required governance framework

Transcription

1 Third Party Delegation The required governance framework

2 Mae r ddogfen yma hefyd ar gael yn Gymraeg. This document is also available in Welsh. Crown copyright 2016 WG28754 Digital ISBN

3 Third Party Delegation The required governance framework Contents Page Foreword 3 Executive Summary 4 Introduction 5 Deciding to Delegate 5 How to use this Framework 7 The Framework 8 1. National Standardised Approach 8 2. Health Boards 9 3. Local Authorities Joint Partnership Agreements Third Party Providers 14 Examples of where citizen centred care has been achieved 16 Powys teaching Health Board & Powys County Council 16 Hywel Dda University Health Board & Carmarthenshire County Council 17 Aneurin Bevan University Health Board 18 Abertawe Bro Morgannwg University Health Board & Bridgend County 19 Borough Council Appendix 1 21 Example of Documentation undertaken by Aneurin Bevan University Health Board Annex 1 21 Situation, Background, Assessment, Recommendation to delegate Annex 2 24 Choice and Control and Risk Enablement Assessment Annex 3 26 Individual Escalation Flow Diagram Annex 4 27 Standard Operating Procedure for delegation of administration of Peristeen to non NHS care workers Annex 5 30 Management of Health & Safety Risk Assessment Form 1B Annex 6 32 Procedure for the management of rectal irrigation Annex 7 35 Personalised procedure for the management of rectal irrigation Page 2 of 37

4 Third Party Delegation The required governance framework Foreword Far too often the users of services in Wales report the multiplicity of people who visit their homes to provide care. This constant un-coordinated disjointed provision of care can reduce the quality of life and life experience of the person receiving the care. Currently there is little understanding across service providers of how the provision of care can be safely delegated to the most appropriate individual while maintaining good governance to support and meet the wishes of the individual receiving that care. The Welsh Government is committed in facilitating a value-based approach to health and care, based on need and which incorporates the citizen s voice in decisions about healthcare and services and to provide better integrated and more citizen focused services. It can though however be difficult to manage because working across organisational boundaries is complex and can involve the need to overcome challenges and risks. Complexity and ambiguity can lead to confusion and weak accountability and this in turn can lead to a reduction in responsiveness, quality and an increase in overall cost. As the nature of 24 hour care now required is changing so there must be consideration of the workforce needed to ensure we have suitably skilled, confident and competent staffed teams able to implement new models and ways of working which will be required under the Social Services & Well-being (Wales) Act It is important that there is a consistent approach to developing the social care workforce that does not detract from their core function but meets the needs of individual citizens and there is clarity with regards to the nature of the care and support that can be offered and the governance framework to support this. The focus of this Framework is on the governance to support integrated care for older people, particularly frail elderly people or those individuals with complex needs. This means ensuring individual citizens have a voice and control over their care and support. It places a strong focus on maintaining well-being through individualised bespoke responses to a persons needs. Fundamental to this is a person centred planning approach that identifies what is important to a person from his or her perspective, building on the strengths people have, and their networks and community contacts, in order to promote independence. It means recognising that many people can only communicate their care needs effectively through the medium of Welsh and for many Welsh speakers being able to use one s own language has to be seen as a core component of care not an optional extra. We must ensure services are co-designed, co-ordinated and delivered effectively, to meet the outcomes that are important to people and their carers. This Governance Framework pulls together the current best practice and Welsh guidance and legislation to support safe and sustainable integrated working across sectors and the governance each stakeholder requires to have in place to maintain an integrated approach to the prudent delegation of tasks to meet the wishes of individuals receiving care. Page 3 of 37

5 Third Party Delegation The required governance framework Executive Summary We want Wales to be a great place for people to live and grow old. People should be able to live the lives they want to and have access to high quality care and support to meet their needs. This is the same whether they are in their own home or a care home. To achieve this we will need individuals, families, communities, health, social services and third and independent sectors all working together. Is this what we want in Wales! John was normally fit and well for an 87 year old, he lived by himself since his wife died two years ago. John s children had moved away for work and he had no local next of kin. John had noted that he had started to forget things and discussed this with his GP. After consulting with a doctor at the local hospital John was prescribed medication that would help with his memory. John was active in the local community volunteering and loved living in the home he and his wife had established and lived in for over 40 years. Unfortunately John kept forgetting to take his daily medication and in discussion with the local pharmacist his medication was reviewed, there were no alternative ways to receive the medication and John trialled the use of assistive technology to help him take his medication as prescribed. This unfortunately did not work well for John and the best support for him to take his medications was to have someone there to prompt him to take it. John was able to continue being part of the community but was becoming frailer with age and was not looking after himself as well. He had started to have daily domiciliary home care support to enable him to stay at home however the home care support did not attend at the time his medication was prescribed and were not asked as part of the care package to prompt medication. John began to feel that he was unable to cope at home and moved into a residential home away from his community, his volunteering stopped and even though he was taking medication regularly his memory deteriorated quite quickly requiring prompting for all personal activities after only a few weeks after admission. The Social Services and Well-being (Wales) Act 2014 gives people a strong voice and real control over the social care services they use. It will drive the development of new models of service to maintain and improve the health and wellbeing of people. There will also be a stronger focus on preventative and early intervention services. This will be achieved through greater partnership working and integration of services. This governance framework pulls together the current best practice and Welsh guidance and legislation to support safe and sustainable integrated working across sectors and the governance each stakeholder requires to have in place to maintain an integrated approach to the prudent delegation of tasks to meet the wishes of individuals receiving care. Page 4 of 37

6 Introduction The Welsh Government is committed to improve outcomes by facilitating better integrated and more citizen focused services. However, it can be difficult to manage because working across organisational boundaries is complex and can involve the need to overcome challenges and risks. Complexity and ambiguity can lead to confusion and weak accountability. This governance framework is designed to help assess whether sound governance arrangements are in place for the delegation of care from NHS Wales employed registered professionals to third party support workers who are not employed by NHS Wales or directly contracted / commissioned by them. The Framework draws heavily on the governance framework for the development of the Health and Social Care Support Worker Role in Adult Services (NLIAH & CC Wales 2012) and the All Wales Guidelines for Delegation (NLIAH 2010) This governance framework does not require joint appointments to health and social care support worker roles to facilitate delegation. Deciding to Delegate Delegation is the process by which the delegator allocates clinical or non clinical treatment or care to a competent person (the delegatee). The delegator will remain responsible for the overall management of the individual s care and is accountable for their decision to delegate. The delegator is not accountable for the decisions and actions subsequently taken by the delegatee. Fundamental to delegation is the context of the relationship that exists between the person who delegates and the person to whom some aspect of practice is delegated. A number of factors have been identified that are significant for those who delegate tasks when deciding to pass a task to a support worker. The person who is responsible for the decision to delegate should follow the assessment process as outlined in the All Wales Guidelines for delegation (NLIAH 2010) Stage 1 of the process is to assess the task to be delegated and the individual undertaking the task. Stage 2 of the process is the action and review of how well the delegatee performs the task. The decision to delegate a task should be undertaken in coproduction with an individual to best meet their needs and should be recorded as part of the integrated assessment, planning and review of the individuals needs. The Integrated Assessment, Planning and Review Arrangements for Older People (Welsh Government 2013) is a person centred planning approach that identifies what is important to a person from his or her perspective, building on the strengths people have, and their networks and community contacts, in order to promote independence. It means meeting the Welsh language standards by recognising that many people can only communicate their care needs effectively through the medium of Welsh and for many Welsh speakers being able to use one s own language has to be seen as a core component of care, not an optional extra. Integrated assessment, planning and review promotes choice, control, independent living, autonomy and staying safe. The registered professional should record around the decision to delegate a specific task: An assessment of the individuals capacity to consent to specific tasks being delegated to support their health/wellbeing Who will best meet the needs of the individual? Consent Risk assessment Is there a need for a third party to carry out the task? o The use of contracts Page 5 of 37

7 o Cost and funding / direct payments Examples of the documentation used by Aneurin Bevan University Health Board are within Appendix 1. Annex 1 is the Situation, Background, Assessment, Recommendation decision to delegate. Where it is identified that the individual does not have capacity to decide that the support worker can undertake the specific task then the delegating health care professional is responsible for ensuring a discussion is held for a Best Interest decision. Discussion should be with the family (and/or those individuals who are deemed to have responsibility for care) of the individual and that a decision is made in the individual s best interest. The best interest decision must be fully documented within the multidisciplinary integrated assessment, planning and review documentation. The All Wales Consent Form must be completed before the task is delegated and the delegator must ensure this is clearly evident in the individual s healthcare notes. Appropriate individuals who may be deemed to have responsibility for the care of an individual may include: Next of Kin Care agency or home manager Social Worker or General Practitioner Who should carry out which task; depends on a number of factors: The requirements of the individual and their own choice The support workers skills, competence, aptitude and experience The nature of the task in the specific circumstances; or If there is a need for a change or introduction of assistive technology to help in meeting the need. The risk assessment process should not be a substitute for professional judgement and experience and should be informed by the knowledge, skill and expertise of the multidisciplinary team undertaking the integrated assessment. It is a process involving thinking about the dangers and risks that an individual may face, recording these and considering proportionate mitigation and where the responsibility will lie. Equally it should not be used as an excuse not to do things unless the likely benefits are outweighed by the likely dangers. A risk assessment must be part of the multidisciplinary integrated assessment process (see annex 5). When delegating to a support worker specified by the individual then a Choice, Control and Risk Enablement Policy should be in place and a Risk Enablement Tool used to highlight risks and to set up an agreed contingency plan if the care arrangements breakdown (see annex 2). The employer of the support worker, whether this is an agency, care home, third sector provider or individual should be aware of and agree to the training, assessment and ongoing supervision / monitoring of the task(s) delegated. The delegator is a named health professional who through local policy or through their job description is required to and able to delegate tasks to a third party. The delegator will remain responsible for the overall management of the individuals care and to maintain openness, transparency and candour for that care. They are accountable for their decision to delegate, undertake appropriate actions to ensure safe delegation (training and assessment of the delegatee) and to undertake or ensure appropriate ongoing supervision / monitoring of the task(s) delegated. The delegator should maintain a register of what they have delegated, who is carrying out the delegated task, the competency they have been Page 6 of 37

8 assessed against and their supervision / monitoring activity (this can be through the electronic patient record Welsh Community Care Information System) for internal audit purposes. The delegator is not accountable for the decisions and actions subsequently taken by the delegatee. Openness: enabling concerns to be raised and disclosed freely without fear and for questions to be answered. Transparency: allowing true information about performance and outcomes to be shared with the individual, staff and the public. Candour: ensuring the patients harmed by healthcare services (and those health tasks delegated) are informed of the fact and that appropriate remedy is offered, whether or not a complaint has been made or a question asked about it. How to use this Framework This framework is based on the current available guidance and support materials within Wales and draws specifically on the guidance that will support successful safe delegation. The Framework is designed to be used primarily by managers developing integrated working across Health and Social Care, as a self assessment checklist. It is divided into 5 areas: 1. National Standardised Approach 2. Health Boards 3. Local Authorities 4. Joint Partnership Agreements 5. Third Party Providers Each area includes elements that need to be in place and links and references to supporting tools and resources. Page 7 of 37

9 The Framework 1. National Standardised Approach Prompts for consideration It is important that there is a consistent approach to developing the social care workforce that does not detract from their core function but meets the needs of individual citizens and there is clarity with regards to the nature of the care and support that can be offered and the governance framework to support this. There is a national repository of best practice guidance / competencies that is easily accessible by Health Boards, Local Authority Staff and Third Party Providers. (NHS Wales Governance e-manual ) Tools & Resources Care Council for Wales, Sector Skills Council for Wales, Skills for Health Nationally agreed competencies o For example: The routine management of compression hosiery for the stable person with lymphoedema The routine management of anti-embolic compression hosiery Medication by support workers Competency Framework to support adults who require home enteral tube feeding via a gastrostomy feeding tube Agored Cymru Unit : Undertaking Home Enteral Tube Feeding in Community Based Settings Page 8 of 37

10 2. Health Boards Prompts for consideration The registered health professional works to a job description and competencies required by the service and are supported through clinical supervision, appraisal, personal development and training plans. The registered health professionals job description specifies the main elements of the role and includes the delegation of tasks to support staff both directly managed and contracted by health and to third party support staff who are supporting an integrated assessment, planning and review plan of care for an individual. Tasks suitable for delegation are identified and agreed as part of the integrated assessment and plan of care. Example of a tool for identifying suitable / not suitable tasks for delegation see Appendix 1 Governance Framework for development of the Health and Social Care Support Worker Role in Adult Services Example of good practice documentation within complex care delegation to delegate medication administration using a specialist technique, undertaken by Aneurin Bevan University Health Board is within Appendix 1 Tools & Resources Welsh Risk Pool Services All Wales Policy on insurance, NHS Indemnity and related risk management for potential losses and special payments %20Final%20-% pdf Welsh Risk Pool Services, Technical note 28 Welsh Risk Pool Services, Technical note 29 Nursing and Midwifery Council, The Code (2015) Nursing and Midwifery Council, Standards for Medicine Management (2010) Health Care Professions Council, Standards of Conduct, Performance and Ethics (2012) Code of Conduct for Healthcare Support Workers in Wales All Wales Guidelines for Delegation (2010) Governance Framework for development of the Health and Social Care Support Worker Role in Adult Services (2012) Page 9 of 37

11 d%20social%20care%20support%20worker%20role%20in%20adult%20services%5b1%5d.pdf Integrated assessment, planning and review arrangements for older people (2013) Putting Things Right version 3 (2013) %20Dealing%20with%20concerns%20about%20the%20NHS%20-%20Version%203%20-%20CLEAN%20VERSION%20%20- % pdf All Wales Guidance for Health Boards / Trusts in Respect of Medicines and Health Care Support Workers (2015) 20of%20Medicines%20and%20HCSWs.pdf Page 10 of 37

12 3. Local Authorities Prompts for consideration Commissioning intentions and contractual agreements that support third party delegation from NHS registered health professionals. Joint integrated contract monitoring systems and processes with the Health Board Tools & Resources All Wales Guidelines for Delegation (2010) Governance Framework for development of the Health and Social Care Support Worker Role in Adult Services (2012) d%20social%20care%20support%20worker%20role%20in%20adult%20services%5b1%5d.pdf SCIE Guide 54, Commissioning home care for older people (2014) All Wales Guidance for Health Boards / Trusts in Respect of Medicines and Health Care Support Workers (2015) 20of%20Medicines%20and%20HCSWs.pdf Page 11 of 37

13 4. Joint Partnership agreements between Health Boards & Social Services Prompts for consideration Partners will need to secure contractual arrangements with third parties such as domiciliary care providers that recognise the requirements to work within this governance framework or have in place a joint partnership Delegation Policy / Agreement o This is an agreement to support registered health professionals delegate tasks. o Supported by a Choice, Control & Risk Enablement Policy Partners undertake joint assessment of health and well-being needs for care support and preventative services (Section 14 Social Services & Wellbeing (Wales) Act 2014). Partners should determine and agree a common and consistent approach to the management and keeping of records. Where service user information is appropriately shared, the arrangements will be determined by Wales Accord of the Sharing Personal Information (WASPI) Partners should determine and agree a Section 33 agreement to support delegation where this is deemed greater than incidental or ancillary to something else that the local authority is doing to meet an individuals needs. (Section 47 Social Services & Wellbeing (Wales) Act 2014) o incidental or ancillary in this instance could be considered when additional significant costs would be incurred rather than related to any particular task being delegated. Tools & Resources Social Services & Wellbeing (Wales) Act National Health Service Act (Wales) Mental Capacity Act 2005 Code of Practice All Wales Guidelines for Delegation (2010) Governance Framework for development of the Health and Social Care Support Worker Role in Adult Services (2012) d%20social%20care%20support%20worker%20role%20in%20adult%20services%5b1%5d.pdf Integrated assessment, planning and review arrangements for older people (2013) A Framework for Delivering Integrated Health and Social Care for Older people with Complex Needs (2014) Page 12 of 37

14 Wales Accord on the Sharing of Personal Information (WASPI) Welsh Risk Pool Services All Wales Policy on insurance, NHS Indemnity and related risk management for potential losses and special payments %20Final%20-% pdf SCIE Adult Services Report 36 Enabling risk, ensuring safety: Self-directed support and personal budgets SCIE Guide 54 Commissioning home care for older people All Wales Guidance for Health Boards / Trusts in Respect of Medicines and Health Care Support Workers (2015) 20of%20Medicines%20and%20HCSWs.pdf Page 13 of 37

15 5. Third Party provider of Support Worker Prompts for consideration Support workers work to a job description and competencies required by the service and are supported through supervision, appraisal, personal development and training plans. Support worker job description specifies the main elements of the role. For example, identification of need for further assessment by a health or social care professional; signposting and health promotion; social care tasks; delegated tasks from a Registered Health Professional (nurse, dietician or other therapist.) The job description makes it clear that the support worker only carries out delegated tasks that are specific to the named service user: o Based on assessment of the service user needs by a registered health professional. o Recorded in the service user s multi-disciplinary plan of care. o Agreed as appropriate to be carried out by the support worker. o Carried out in accordance with agreed protocols for specific tasks. o Tasks for which the support worker has been trained and assessed as being competent to undertake and that are under a planed monitoring and supervision regime. o Delegated tasks are not transferable to other support workers unless they have been through the delegation process and have been delegated to undertake the task with the service user by the delegating Registered Health Professional. o Delegated tasks are not transferable to other service users unless they have been specifically delegated by the delegating registered health professional. The support worker has a duty to inform the delegator and / or their line manager if they do not feel competent or do not have the capacity to undertake the task/s which is being delegated. The support worker job description includes reference to the Codes of Conduct and Practice. Appropriate levels of Insurance and Indemnity are in place and are clearly agreed within any contractual arrangements. Tools & Resources Code of Conduct for Healthcare Support Workers in Wales All Wales Guidelines for Delegation (2010) All Wales Guidance for Health Boards / Trusts in Respect of Medicines and Health Care Support Workers (2015) 20of%20Medicines%20and%20HCSWs.pdf Governance Framework for development of the Health and Social Care Support Worker Role in Adult Services (2012) Page 14 of 37

16 d%20social%20care%20support%20worker%20role%20in%20adult%20services%5b1%5d.pdf National Minimal Standards for Care Homes for Older People CSSIW (2004) National Minimal Standards for Domiciliary Care Agencies in Wales CSSIW (2004) Welsh Risk Pool Services All Wales Policy on insurance, NHS Indemnity and related risk management for potential losses and special payments %20Final%20-% pdf Page 15 of 37

17 Examples of where citizen centred care has been achieved The delegation of tasks by NHS Health Professionals to non NHS support staff is not new and is being undertaken across Wales; however the implementation, impact and learning of this has been undertaken at a very local level. The following examples from across Wales demonstrate good practice and well managed governance to enable safe citizen centred bespoke care to meet the needs of individuals. Where Citizen Centred Care has been achieved Allan is 50 years old with paraplegia who required supervision in checking his own blood glucose and giving his own insulin and overseeing intermittent catheterisation. His mother was his main carer until she passed away following this Allan had new live in carers and the District Nursing Team called in every day. The District Nursing Team were able to provide the appropriate training and supervision to the live in carers and over a period of two months were able to pass all Allan s care to the live in carers. The District Nursing Team now only calls once a fortnight to monitor care provided and Allen does not feel like a patient, who has visits from multiple district nursing staff each week. Mavis is in her early 50's who has Multiple Sclerosis and is wheelchair bound. The District Nursing Team was visiting her every 3 days to replace her analgesic patch. After liaising with Medicine Management Team the District Nursing Team were able to provide the appropriate training and supervision for the carers to do this. The District Nursing Team now only call every 8 weeks to monitor the care provided and to monitor Mavis pressure areas. Robert is in his 80 s and requires a Juxta System compression arm sleeve to his left arm for lymphedema. The sleeve is difficult to get on and off without assistance and requires removing daily prior to washing and reapplying prior to dressing. The district nurses were attending everyday to support Robert, however timing their visit so as not to disrupt Roberts day and enable him to get fully dressed was very challenging. Roberts s wife supported him in his activities of daily living such as washing and dressing but was not confident in supporting with the compression sleeve. As supporting Robert with washing and dressing became too much for her carers were engaged to support him in this. Following appropriate training and supervision the carers were able to remove and reapply the compression sleeve enabling Robert to wash and dress immediately and improve his quality of life. His wife was also taught as she had seen the carers undertaking this and is now able to support Robert and maintain her continued active input in his care. She has found this beneficial to her as she feels she is able to contribute to Roberts care. The district nurses continue to visit Robert 2 to 3 times per week to support other aspects of his care and to monitor, support and assess the care of his lymphedema. Page 16 of 37

18 Where Citizen Centred Care has been achieved.. This was a project supported by the Intermediate Care Fund between Hywel Dda University Health Board and Llys Y Bryn a Local Authority owned residential care home of 45 beds. The project focused on Non Complex Wound Care a high volume, time intensive health task that would yield maximum benefit for the residents and the service. To enable safe delegation of this task for named residents as part of their integrated plan of care the Hywel Dda University Health Board s support worker programme; Excellence, Assurance and Governance in a Learning Environment (EAGLE) was used supported by AGORED Cymru training. The District Nursing Team committed to supporting the residential home carers through managed supervison, monitoring and review of the care, and this was made possible by the release of their time from undertaking the health tasks directly. There has been no detrimental impact to the clinical outcomes, the residents are reporting an improved quality of life as they are able to have simple wound dressings undertaken at a time convenient to them, and there is no requirement for them to undertake unnecessary dressing, undressing to facilitate the wound dressing changes. The relationship between the District Nursing Team and the residential home staff has been strengthened and an improvement in record keeping has been noted. The residential home staff feel valued and are a more confident work-force who now want to learn new skills. Though there were initial set up costs of the training and supervised practice these have been recoup within 6 months as the District Nursing Team is now spending about 50% less time within the home and this time is now spent ensuring the quality of the care provided through the supervision, monitoring and on-going review of the delegated tasks. Since implementation the residential home has not experienced additional costs related to their care staff undertaking these tasks. The plan is to extend the delegated health tasks for individual residents based on their individual plan of care through activities such as basic observations and will include: temperature, pulse and blood pressure, blood glucose (finger prick) monitoring and the administration of eye drops and topical creams. Page 17 of 37

19 Where Citizen Centred Care has been achieved Jenny is a young woman with profound learning disabilities resulting in multiple and complex health needs who lived with her parents. Whilst both parents were currently able to meet Jenny s health and social needs they were mindful of the future and were keen whilst they were themselves in good health able to ensure that Jenny was settled in an environment where she would be safely cared for and which they can participate in planning. Residential placement in a local home where they could continue to participate in Jenny s life, supported by day centre activities, day trips and holidays was the preferred option as it enabled holistic care as Jenny s social needs outweighed her health needs. Jenny has a percutaneous endoscopic gastrostomy (PEG) which enables access for administration of all nutritional, hydration and medication needs. This was the main obstacle to facilitate a transition into the residential care home of choice as the constraints due to the necessary timetabling for the district nurse interventions would significantly limit Jenny s options of attending social activities and the activities organised by the Day Centre, adversely impact upon her quality of life. A bespoke package of care was developed for Jenny in partnership with her family, the Residential Home and Day Centre. The District Nurse (DN) Team Leader was the most appropriate care coordinator for Jenny. Through the DN Team Leader the safe management of the PEG including administration of all nutritional, hydration and medication needs was safely delegated to named care staff at both the Residential Home and the Day Centre. Delegation to a third party was made a routine requirement of the DN Team Leaders role through their job description and delegated tasks from health professionals became a routine part of care staff through their job descriptions with the Residential Home and Day Centre provider. Full training supported by training materials and local visual prompts were given to the support staff and their competencies were signed off by the DN Team Leader. Full support was also gained from the local community pharmacy over the supply and provision of medication and Medication Administration Records charts. The DN Team Leader continues to support through a planned supervision and monitoring regime and a full contingency plan is in place. If for any reason the Residential Home or Day Centre is unable to meet Jenny s needs the District Nursing Team will step in and support. Jenny now lives away from home supported through residential care and attends social activities arranged by a local day centre. The flexibility in her regular carers being able to meet all her health and social care needs means she is able to participate in all activities. Jenny s parents are able to visit and pop round and still be an active part of Jenny s life and social circle. The care staff at the Residential Home and Day Centre really value the support they receive from the District Nursing Team and feel that they are really making a difference in Jenny s life. The District Nursing Team value the contribution and impact the care staff are able to have in Jenny s life and the real difference this has made. Page 18 of 37

20 This bespoke package of care through collaborative working safe, effective care through consistency of carers, regular evaluation and ongoing support by the DN Team has been fully reviewed by ABUHB. The implementation of this integrated package of care has demonstrated that fragmentation of care can be avoided and that ultimately unnecessary costs of registered health professionals interventions can be saved while delivering a higher quality service and experience to the individual. Where Citizen Centred Care has been achieved JD is a very sociable 22 year old who lives with her parents. She is severely disabled, a wheelchair user, has quadriplegic cerebral palsy and hydrocephalus, and has had many medical problems in the past. She also has had scoliosis, a hip dysplasia which gives her pain, and is fed using a PEG. Up until 19yrs of age, JD received respite along with support from the Paediatric Community Nursing Team. On transition to adult services a number of issues arose which denied her access to routine adult respite and adult day services. Within the existing community PEG feeding was being undertaken by paid carers, and had been for some time, however the complexity of JD s presenting needs complicated the delivery of care by social service staff. A multi-professional risk assessment and management plan was in place in readiness for JD to access services. The challenge for local services at the time was that Social Services did not agree that PEG feeding was within their remit and refused her access unless trained registered nurses accompanied her to respite. However there was already a recognised risk management plan in place. The family complained to the Ombudsman and Welsh Government resulting in the commissioning of an organisation called Kafka Brigade UK. This is an independent not- for- profit action research team specialising in organisational bureaucratic dysfunction The experience of the family highlighted the need to ensure a more consistent and effective approach to PEG feeding, that is centred on the needs of the service user. Identified Actions: Training to be provided for staff to undertake PEG feeding including medicine administration and routine PEG care. To develop a joint Service Level Agreement between health and the local authority Due to an inconsistent approach to community PEG feeding across Wales a review of PEG feeding practices was directed by the then the Welsh Assembly Government. Page 19 of 37

21 Outcomes: An agreed joint PEG protocol was formulated and is in current use. There have been no clinical incidents. All respite and day services staff partake in a rolling education programme. Independent sector care providers are checked to ensure that their staff are appropriately trained. Up-to-date care plans and risk assessments are in place for each PEG-using client. The All Wales Task & Finish Group reviewed guidance and a consultation document called The All Wales Competency Framework to support Adults who require Home Enteral Tube Feeding via a Gastrostomy Feeding Tube Last but by no means least, JD enjoys access to a variety of community activities, local respite supported by a dedicated cohort of paid care staff specifically trained in PEG management. This is a bespoke person-centred package jointly overseen by Health and Social care. Page 20 of 37

22 Appendix 1 Example of documentation and assessment undertaken by Aneurin Bevan University Health Board (ABuHB) Annex 1 Team : District Nursing services /CHC Continuing Health Care Site: Community Division S In February 2015 the community division sought to establish a bespoke package of care, for an individual with complex needs. Such proposals offer continuity of care and secure quality and patient safety within a formal delegation framework This Standard Operating Procedure identifies the requirements when leading and managing practice for health and safety in a community setting for delivery of a bespoke package of care for the delegation of Peristeen rectal irrigation to client XY B XY is a young paraplegic on the district nurses caseload who wishes to direct his own care at a time & pace to suit his own lifestyle & be independent of the constraints of timetabling for district nursing interventions XY can express his own wishes and articulated a wish for this aspect of his care to be delivered by his Care Provider under his direction to support his dignity, privacy and flexibility of care Carers are not employed by ABuHB and are contracted by them to meet XY Continuing NHS Health Care needs. The District Nursing Team Leader as the Care Coordinator escalated XY wishes for this aspect of his care to be delegated. The District Nursing Team Leader as the Care Coordinator is happy to undertake the required training of the care provider s support workers to deliver this aspect of XY care and to provide ongoing supervision and monitoring, and provide the appropriate contingency plan to mitigate any risks of care package breakdown. The District Nursing Team Leader has within their normal job role as recorded in the roles job description the delegation of health tasks to health care support workers and third party support workers. Page 21 of 37

23 A Assessment R Recommended Action By when Supporting Document Aim- Need to offer flexibility of care for Development of a bespoke care package Feb 2015 This SBAR administration of Peristeen Objective- To safely and effectively deliver a bespoke package of care Development of a bespoke governance framework informed by local and national best practice and guidance By implementation of the bespoke package of care, the constraints of timetabling for district nursing interventions can be removed The patient s wishes were paramount and central to the development of this bespoke package to enable his choice, control and risk Feb 2015 This SBAR Choice, Control and Risk Enablement Standard Operating Procedure (SOP) required enablement around his own care needs. XY has capacity to make decisions about his on-going care. XY has requested that his administration of Peristeen be undertaken by his carers rather than being confined to times when the District Nursing Team can schedule the visits. Undertake a Choice, Control and Risk Enablement Assessment Complete a Consent Form for Peristeen to be administered by his carers. Developed an individual care plan which assessed all the potential risks for the management/administration of Peristeen. This enabled an escalation process through the ABuHB nursing structure in the event of an adverse incident Feb 2015 Feb 2015 Choice Control and Risk Enablement Assessment (Annex 2) XY Unwell Flow Diagram (Annex 3) Standard Operating Procedure (Annex 4) Need to ensure all aspects relating to health and safety were considered Robust transitional arrangements in place in collaboration with the District Nursing Team, and the patients family Risk assessments 1a and 1b completed Feb 2015 Peristeen 1B risk assessment form (Annex 5) Close liaison with CHC and the DN team to ensure all timetabling in place whilst training programme being delivered and competences being assessed Feb 2015 Page 22 of 37

24 Developing a training programme Educational Programme delivered by the District Nursing Team District Nursing Team have been taught Peristeen procedure by Coloplast Peristeen Nurse Representative A Competency Framework was developed and aligned to Wirral Policy for Peristeen administration District Nursing Team have been taught Peristeen procedure by Coloplast Peristeen Nurse Representative DNs have been signing off carers by demonstrating the procedure & the carer undertaking this under DN supervision Feb 2015 Feb 2015 Competency Rectal Irrigation Documentation (Annex 6) XY Personalised Competency Rectal Irrigation Document (Annex 7) DNs teach all new carers and continue to do this including refreshers until the carer is comfortable with the procedure Collaboration with Coloplast Nurses to further support delivery of training programme. Continence Nurse specialist undertook assessment of suitability for Peristeen rectal irrigation for XY as per ABuHB Continence Nurse specialist role when this was initiated Active Assist link with Coloplast who manufacture Peristeen for training updates for carers in their employment Specialist support and expertise to ensure all needs for XY were anticipated and met through evidence based skills development Feb 2015 Page 23 of 37

25 Annex 2 Choice and Control and Risk Enablement Assessment Part 1 Name of Service User: XY Name of care Coordinator: XX Date of Assessment: Feb 2015 Nature of Risk XY would like to have his carers undertake his complex medication regime. Due to specialist technique and risk of hospitalisation through poor administration this is of High to Extreme risk if medication not given as prescribed. Negligible Minimal Moderate High Extreme The individual is not taking medication Is taking prescribed medication, there is minimal risk to the individual or others from missing this medication on a short term basis. Occasionally forgets to take medication / Some problems with reading or understanding the labels and instructions for medication / Some difficulty in managing medication ordering, storing etc / A level of specialist medication / Need to be reminded or supervised in taking medication / Requires regular pain relief / Some risk of overdoes Requires support with all aspects of medication / Cannot manage medication without support/ Risk of overdose / Medication administered by specialist technique / Chaotic approach to medication / Potential to be abused through medication (over provided or with held (SAFEGUARDING) Concerns about medication are serious and risk is imminent / Welfare, health and independence are at risk due to medication issue (eg Unconsciousness) DO YOU NEED TO CALL 999 Mitigation Is it in XY best interest to delegate this task? Yes as it enables XY not to be constrained by the scheduled visits from a registered health professional and all his care can be undertaken by his regular carers. Is it possible to safely delegate this task? Yes the competencies for the giving of this medication can be supported and undertaken by support workers. Can an appropriate individualised plan of care be sustainably implemented? Yes please see SBAR and attached documents Page 24 of 37

26 Part 2 Name of Service User: XY Name of care Coordinator: XX Date of Assessment: Feb 2015 Risk Enablement Panel Members Title Service User Locality Manager Care Coordinator Advocate / Family Member Appropriate Head of Profession (Nursing) Professional Leads (Pharmacist) Other specialist advisors (Legal and or clinical) Key Worker Care Provider Representative Admin Support (Minute Taker) Present XY TT XX PY PL JC CR Specialist Nurse AB DE JJ Panel Chair TT Locality Manager Documentation Reviewed SBAR Flow Diagram Standard Operating Procedure Competency Requirements Discussion It is totally correct and proper that XY is able to live as normal a life as possible and is not restricted in his activities due to the scheduling of registered health professionals to attend his residence to undertake this procedure. Though this procedure has not been undertaken before locally the training, monitoring and supervision of the support workers and the adequacy of the competence pack successfully outweigh the risks of support workers undertaking this task for which they are best placed to undertake at XY s convenience. Outcome of Discussion To enable XY to have his paid carers undertake the administration of Peristeen rectal irrigation. Page 25 of 37

27 Annex 3 Individual Contingency Escalation Flow Diagram XY Unwell Flow Diagram Generally Unwell Carers / Family Present XY Carers / Family to contact the GP If XY condition deteriorates and becomes less well Carers / Family to Call 999 AD = Autonomic Dysreflexia Suddenly Unwell / AD Symptoms Carers / Family Present If AD Symptoms / sweating Remove potential stimulus if known XY /Carers / Family Consider giving ADALAT sublingual medication AD symptoms begin during administration of Peristeen Rectal Irragation with Carer XK / Carer Release water immediately from Peristeen Rectal Irrigation Device to remove stimuli If AD symptoms persist XY / Carers / Family Consider giving ADALAT sublingual medication If carers need advice re Peristeen to contact DN s am 8pm Blocked Catheter Carer Present Carers try 2 X pulsating Supra Pubic Catheter Washouts If not successful contact DN s am 8pm DN s have 2 hour response time If outside of DN hours or there is a delay in DN response call If AD symptoms and re-cathertisation is not successful by DNs XY /Carers / Family Consider giving ADALAT sublingual medication If Family not present Carers to contact and inform Family of 999 call No improvement Carers / Family to Call 999 No improvement Carers / Family to Call 999 No improvement Carers / Family to Call 999 Page 26 of 37

28 Annex 4 Standard Operating procedure for delegation of administration of Peristeen to non NHS care workers This SOP identifies the requirements when leading and managing practice for health and safety in a community setting for delivery of a bespoke package of care for the delegation of Peristeen rectal irrigation to client XY Identified risk In the event of an accident - An accident may be a major or minor incident that is unforeseen and causes injury; accidents may be due to falls; hazards in the environment; illness; disability; weaknesses; sensory and cognitive impairment DN Team may be unfamiliar with Peristeen Irrigation & may have New team members in post Escalation process Immediate notification to DN services DATIX report to be completed Escalation to DN team leader to address training needs Existing controls Actions to be taken Key individuals to be informed Individualised risk Immediate assessment of patient assessment in place condition Peristeen rectal irrigation was instigated after assessment of patients suitability by ABuHB Continence Nurse Specialist Patient has capacity & chose this method of bowel management in full knowledge of the potential complications that can occur Individualised training programme in place specific to patients needs DATIX reporting by DN team DN team to have training update from Peristeen Nurse employed by Coloplast DNs already competent to supervise and train new team members Patient able to advise & direct how he wishes procedure to be carried out DN team to inform senior nurse during working hours. Outside these hours, senior nurse on call to be advised. Decision to be made regarding need for escalation to Divisional lead nurse and executive nursing team DN team leader Monitoring of outcome DATIX report investigation and outcome DN team leader Page 27 of 37